Welcome to LSURR.ORG

LETTER OF INTEREST

Please fill in this form and press "submit" if you are interested in joining the Team.

Diver candidate:

Support Candidate:

Name:
Address:
Address2:
City, State, Zip
Home Telephone
Work Telephone
Mobile Telephone
E-Mail
Date of Birth "MM/DD/YYYY"
Spouse's Name
Emergency Contact
Emergency Contact #
Current Employer
Ocupation

EXPERIENCE Mark all that apply

Name	Certified	Agency	Expiration
CPR
CPR Trainer
Lifeguard
Para-Medic
First Aid

Name	Active	Department
Public Safety Officer
Fire Professional

CORE DIVING CERTIFICATIONS Please complete the following fields if you are a Diving Candidate only.

CERTIFICATION LEVEL	AGENCY	STUDENT #	YEAR OBTAINED

SPECIALTY CERTIFICATIONS

CERTIFICATION LEVEL	AGENCY	STUDENT #	YEAR OBTAINED

PERSONAL DIVING EXPERIENCES

Describe your best dive:

Purpose of this dive:

LOCATION	CURRENT	GAS USED	VISIBILITY	MAX DEPTH

Describe your worst dive:

Purpose of this dive:

LOCATION	CURRENT	GAS USED	VISIBILITY	MAX DEPTH

Describe your most technically challenging dive:

Purpose of this dive:

LOCATION	CURRENT	GAS USED	VISIBILITY	MAX DEPTH

REFERENCES Please let us know of a few people who can discuss your diving and personal values with us.

Name:	Telephone:
Name:	Telephone:

GENERAL QUESTIONS How will the Dive Team benefit from your membership?

What tasks of diving make you most uncomfortable?

Any prior experience working with Public Safety agencies?

This is not a dive club. When a call for assistance comes out, each person is depended upon to respond when not at work. Are you willing to be on-call 24 hours a day 7 days a week, except hours at work? Answer?

Comments:

When you select the "Submit" button below, your "Letter of Interest" will be sent to the Diving Control Board" for review and follow-up. You should expect to have a response, either via e-mail, telephone, or post within a week. If not, please re-submit this form.

Thank you!

this form form

Lee's Summit Underwater Rescue and Recovery